University Health
Clinical Reviewer Utilization Management
Universal City, California, US
Role snapshot
University Health is hiring a Clinical Reviewer Utilization Management on a full-time basis. This is a role based in Universal City, California, US.
- Company
- University Health
- Location
- Universal City, California, US
- Job type
- Full-time
- Posted
- Nov 7, 2026
Who this role suits
The listing does not state a required experience level here. Read the requirements in the description below and apply if they match your background.
How to prepare your application
- Match your résumé to the requirements in the description, using the same wording where it is honest to do so.
- Prepare a short example for each requirement you meet, and be ready to explain any you only partly meet.
- Read what University Health publishes about its product or team, so you can say clearly why this role and this company.
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About the role
POSITION SUMMARY AND RESPONSIBILITIES
Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.
EDUCATION/EXPERIENCE
Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.
Working knowledge of:
• NCQA Utilization Management Standards
• URAC Utilization Management Standards
• CMS Managed Care requirements
• Texas Medicaid Managed Care regulations
• Medicare requirements, Medical necessity review criteria (InterQual®, MCG®, or organization-approved criteria)
• ICD-10-CM, CPT, and HCPCS coding principles
• Utilization management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management
• Regulatory compliance, documentation standards, and turnaround time requirements.
Experience reviewing Medicaid, Medicare, Marketplace, Commercial, CHIP, Dual Eligible Special Needs Plans (D-SNP), or other government-sponsored healthcare programs preferred. Experience in a managed care organization, health plan, delegated entity, or other regulated healthcare environment preferred.
LICENSURE
Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required. A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management-related certification preferred.